[Minimally Invasive Cancellous Bone Graft Harvesting in Trauma Indication - Clinical Part of the Study]. / Miniinvazivní odber spongiózních stepu v traumatologické indikaci ­ klinická cást studie.

PURPOSE OF THE STUDY The clinical prospective study presents the results of minimally invasive harvesting of cancellous bone tissue in trauma indications. We focused on evaluating the clinical outcomes of this technique, particularly on the amount of cancellous bone harvested, the effectiveness of its use and complications. The pain in the bone graft harvest site is evaluated and compared with the pain after a standard harvest from the iliac crest. MATERIAL AND METHODS All the patients aged 18-90 years, in whom cancellous bone was harvested by minimally invasive technique using a bone cutter were included prospectively in the study. It was used to fill the defect in treating a fracture or in surgical treatment of non-union. The patients, in whom the grafts harvested in this manner were combined with another substitute, were not included in the study. Thus, 57 adult patients (40 men, 17 women) were included in the group in the period from March 2012 to March 2016. 37 patients, i.e. 65% of the total number of 57 patients, arrived for the evaluation of the clinical outcome. The minimally invasive graft harvesting was performed using the Aesculap® cutters. The graft was harvested either from the skeleton directly in the area of surgical wound or by a mini incision above the harvest site in the area under surgical drapes. The diameter of the cutter was selected based on the planned necessary number of grafts and with account taken of the harvest site. There were 6 harvest sites selected - proximal humerus, proximal ulna, iliac crest, greater trochanter of femur, distal femur and proximal tibia. The age and gender of patients, harvest site, type of the used cutter and the total number of harvested grafts were recorded in the study. The patients underwent a clinical follow-up at 6 weeks, 3 months, 6 months and 1 year postoperatively. The healing of the fracture or non-union was assessed on radiographs and in case of any doubt a CT scan was indicated. The pain at the graft harvest site was quantified with the use of the VAS score. A possible correlation between the age and the harvest site pain was explored by means of the Pearson s correlation coefficient. RESULTS In surgical management of fractures, 10.98 cm³ of bone marrow (σ 5.32) was harvested on average, in non-unions it was 10.85 cm³ (σ 5.52). With the above described technique, the mean healing time of lower extremity fractures was 26 weeks, in upper extremity it was 22 weeks. The non-unions of lower extremity and upper extremity healed after 28 weeks and 19 weeks, respectively. The average pain at the harvest site was 4.08 (σ 2.21, p ˂ 0.001). By calculating the Pearson's correlation coefficient it was confirmed that there is no correlation between the age and pain VAS score at the harvest site (r = -0.05). No early complications at the graft harvest site were observed in our group of patients. DISCUSSION On average, 10.98 cm³ of bone marrow was harvested in treated fractures, which in comparison to standard harvests from the iliac crest offers sufficient amount of tissue to treat complicated fractures and non-unions. Technically, the standard harvest site of cancellous bone tissue from the iliac crest is replaceable. The harvesting technique offers an interesting alternative also in terms of the duration of surgery and material. CONCLUSIONS Our study confirmed that by the minimally invasive technique of bone graft harvesting adequate amount of tissue to treat defect fractures and non-unions can be harvested. Spongioplasty using grafts harvested in this manner is effective, with a minimum percentage of non-unions. The advantage of this technique is the proximity of the harvest site and the operative field and low level of pain. The minimally invasive graft harvesting represents a technique with a low risk of postoperative and late complications. Key words: bone graft, autografts, minimally invasive surgery, ilium, pain.

[Minimally Invasive Cancellous Bone Graft Harvesting in Trauma Indication - Experimental Part of the Study]. / Miniinvazivní odber spongiózních stepu v traumatologické indikaci ­ experimentální cást studie.

PURPOSE OF THE STUDY Our experimental study presents a set of bone grafts harvested by a minimally invasive procedure from selected deceased donors. Our objective was to compare the concentration of red bone marrow in the cancellous bone harvested in this way from selected regions with the reference harvesting from the iliac crest. Thus, the potential of grafts to heal complicated fractures or non-unions is assessed. MATERIAL AND METHODS The Hospital Department of Pathology provided 10 cadaver preparations - 7 male and 3 female for the experiment. In the process of selection, the age limit was 18-50 years, the other exclusion criteria were severe injuries and burning to death as mechanisms affecting the condition of the skeletal system, bone diseases except for osteoporosis, and malignant diseases. From each preparation, a total of 12 samples of cancellous bone tissue were harvested from pre-defined 6 harvest sites bilaterally - proximal humerus, proximal ulna, greater trochanter of proximal femur, distal femur, proximal tibia and from the reference region of the iliac wing. The grafts were harvested using a 10 mm bone cutter. In total, 120 samples of cancellous bone of the determined diameter and uniform length of 30 mm were obtained. The obtained preparations were laboratory processed, fixed, decalcified and hematoxylin-eosin stained. The samples were assessed microscopically. The share of the bone tissue and cancellous bone was expressed as a percentage. Determined as a healing potential parameter was the concentration of red bone marrow and its ratio to the yellow bone marrow was stated. The hypothesis was tested using the ANOVA analysis of variance. RESULTS The highest concentration of red bone marrow was observed in cancellous grafts harvested from the iliac wing with 34.95%, followed by greater trochanter of proximal femur with 31.7%, distal femur with 26.9% and proximal humerus with 21.9%. Its concentration was negligible in proximal tibia with 2.55% and proximal ulna with 0.15%. By ANOVA statistical method the values of reference samples from the iliac wing and greater trochanter of the femur, distal femur and proximal humerus were compared. The differences are not statistically significant - P 0.60, 0.48 and 0.34 (p < 0.05). No significant differences were found in the concentration of red bone marrow. Statistically compared were also the values of reference samples from the iliac wing and proximal tibia, proximal ulna. This difference is statistically significant - P 0.0008 and 0.0002 (p <0.05). Thus, the difference in the concentration of red bone marrow is obvious. DISCUSSION The aforementioned results suggest that the greatest potential to heal will be achieved with the use of bone grafts from the iliac wing region, followed by greater trochanter of the femur, distal femur and proximal humerus. When testing the hypothesis by the ANOVA method, the detected differences between the selected harvest regions are not statistically significant. Therefore, the iliac wing grafts can be used in practice just as the material from greater trochanter of the femur, distal femur or proximal humerus, which is of equal quality. The other regions, proximal tibia and ulna, contain only minimum concentration of red bone marrow. CONCLUSIONS The experimental study comparing the concentration of red bone marrow in grafts harvested using a minimally invasive procedure from the region of greater trochanter, distal femur and proximal humerus concluded that these samples are comparable with the grafts from the iliac wing. The grafts harvested from proximal tibia and proximal ulna show only negligible concentration of red bone marrow and their use in clinical practice is disputable. The benefits of our experimental study for treatment shall be further evaluated in a clinical study. Key words: bone marrow, stem cells, bone healing/orthobiologics, new technology assessment, autograft harvesting.

A Novel Mutation in the FECH Gene in a Czech Family with Erythropoietic Protoporphyria and a Population Study of IVS3-48C Variant Contributing to the Disease.

Erythropoietic protoporphyria (EPP), a chronic erythropoietic porphyria, is characterized by excess accumulation of protoporphyrin, particularly in erythroid cells. EPP inheritance is complex, almost always associated with two molecular defects. In most EPP patients, clinical expression requires coinheritance of a private ferrochelatase (FECH) mutation trans- to a hypomorphic FECH*IVS3-48C allele. This leads to a decrease of FECH activity below the critical threshold. This is characterized by cutaneous photosensitivity in early childhood such as itching, burning, swelling and redness in sun-exposed areas. Hepatic failure occurs in some patients (about 1-10 % of EPP patients), which may necessitate liver transplantation. We investigated a Czech family with two patients with manifested EPP in four generations. We found a novel mutation, c.84G >A, in the FECH gene in four individuals including proband and his mother (G84A transition in exon 2; p.W28*). Both clinically manifested probands inherited the hypomorphic IVS3-48C allele as well, while two clinically latent individuals with FECH mutation did not. To address the question whether the relatively low incidence of EPP in the Czech Republic might be due to lower frequency of the IVS3-48C allele, we screened for the frequency of the low expression allele in a control Czech (West Slaves) Caucasian population. Such study has not been performed in any Slavic population. Among 312 control individuals, there were no IVS3-48C/C (c.68-23C-T) homozygotes; 35 IVS3-48C/T heterozygous individuals were detected. The frequency of IVS3-48C allele was thus found to be 5.5 % in the Czech population, comparable to most West Caucasian populations.

Historical epidemiology of hepatitis C virus (HCV) in selected countries.

Chronic infection with hepatitis C virus (HCV) is a leading indicator for liver disease. New treatment options are becoming available, and there is a need to characterize the epidemiology and disease burden of HCV. Data for prevalence, viremia, genotype, diagnosis and treatment were obtained through literature searches and expert consensus for 16 countries. For some countries, data from centralized registries were used to estimate diagnosis and treatment rates. Data for the number of liver transplants and the proportion attributable to HCV were obtained from centralized databases. Viremic prevalence estimates varied widely between countries, ranging from 0.3% in Austria, England and Germany to 8.5% in Egypt. The largest viremic populations were in Egypt, with 6,358,000 cases in 2008 and Brazil with 2,106,000 cases in 2007. The age distribution of cases differed between countries. In most countries, prevalence rates were higher among males, reflecting higher rates of injection drug use. Diagnosis, treatment and transplant levels also differed considerably between countries. Reliable estimates characterizing HCV-infected populations are critical for addressing HCV-related morbidity and mortality. There is a need to quantify the burden of chronic HCV infection at the national level.

[Reactivation of chronic hepatitis B]. / Reaktivace chronické hepatitidy B.

Hepatitis B (HBV) is a DNA virus, which cannot be eradicated completely from the organism by treatment, only its replication can be suppressed to low levels. The pathogenesis of liver damage due to HBV is immune mediated, the infected hepatocytes represent the target structures of immune reaction. In individuals who spontaneously achieved the state of inactive carriage of the virus or even achieved HBsAg negativity, we deal only with immune control of viral replication. Chemotherapy or immunosuppressive treatment disrupt the immune control of HBV infection, the virus replication substantially increases and hepatitis B reactivates. HBV reactivation manifests as further flareup of chronic inflammation with rapid progression of liver cirrhosis or even as a fulminant hepatitis with liver failure. The risk of reactivation increases with degree of induced immunosuppression, the highest risk is associated with corticosteroid and rituximab therapy. HBV reactivation threatens patients during solid tumours treatment as well as haemato oncological malignancies, patients treated with immunosuppressive and bio-logical therapies for systemic inflammatory diseases and inflammatory bowel diseases, as well as patients on maintenance haemodialysis, after kidney transplantation and patients with HBV/ HIV co infection. HBV reactivation increases both morbidity and mortality in listed groups of patients. The patients threatened by HBV reactivation can be identified easily based on HBV serological markers assessment. Preemptive therapy with nucleos(t)ide analogues significantly reduces the risk of HBV reactivation, the effect of longterm antiviral therapy is described in detail in kidney transplant recipients in whom the 3rd generation antivirals (entecavir and tenofovir) completely obviate the negative impact of HBV on longterm survival. In oncological patients who are treated for a determined time period, we can use lamivudine, which is not suitable for longterm treatment due to high risk of resistance emergence.

[Fibrosing cholestatic hepatitis--disease not only of transplanted patients. A report of eight cases]. / Fibrotizující cholestatická hepatitida--onemocneni nejen transplantovaných pacientu.

Fibrosing cholestatic hepatitis (FCH) is a rapidly progressive, sometimes fatal form of hepatitis B or C in patients who are under immunosuppressive treatment. This condition was originally described in hepatitis B virus-infected recipients after a liver transplantation. It is characterized clinically by cholestatic hepatic dysfunction, and pathologically by marked hepatocyte swelling, cholestasis, periportal peritrabecular fibrosis, and only mild inflammation. Here we present 8 patients with hepatitis B and C related FCH. Three patients developed FCH after liver transplantation, two of them died due to hepatic failure. One recipient of a kidney/pancreas transplant developed "de novo" hepatitis C with features of FCH. He underwent antiviral treatment and survived with good liver function, unfortunately both of his grafts failed. Four patients suffered from a reactivation of their respective hepatitis B infections after chemotherapy treated hematological malignancy. Three of them needed an urgent liver transplantation and survived with good liver function and with a remission of their hematological diseases. The last patient died due to liver failure. Although FCH is a rare variant of viral hepatitis, it should be emphasized that prompt diagnosis is important for the management of patients.

Artificial intelligence assistance improves reporting efficiency of thoracic aortic aneurysm CT follow-up.

OBJECTIVE: Follow-up of aortic aneurysms by computed tomography (CT) is crucial to balance the risks of treatment and rupture. Artificial intelligence (AI)-assisted radiology reporting promises time savings and reduced inter-reader variabilities. METHODS: The influence of AI assistance on the efficiency and accuracy of aortic aneurysm reporting according to the AHA / ESC guidelines was quantified based on 324 AI measurements and 1944 radiological measurements: 18 aortic aneurysm patients, each with two CT scans (arterial contrast phase, electrocardiogram-gated) with an interval of at least six months have been included. One board-certified radiologist and two residents (8/4/2 years of experience in vascular imaging) independently assessed aortic diameters at nine landmark positions. Aneurysm extensions were compared with original CT reports. After three weeks washout period, CTs were re-assessed, based on graphically illustrated AI measurements. RESULTS: Time-consuming guideline-compliant aortic measurements revealed additional affections of the root / arch for 80 % of aneurysms that had initially been reported to be limited to the ascending aorta. AI assistance reduced mean reporting time by 63 % from 13:01 to 04:46 min including manual corrections of AI measurements (performed for 33.6 % of all measurements with predominance at the sinuses of Vasalva). AI assistance reduced total diameter inter-reader variability by 42.5 % (0.42 / 1.16 mm with / without AI assistance, mean of all patients and landmark positions, significant reduction for 6 out of 9 measuring positions). Conventional and AI-assisted quantification aneurysm progress varied to small extent (mean of 0.75 mm over all patients / landmark positions) not significantly exceeding radiologist's inter-reader variabilities. CONCLUSIONS: Guideline-compliant aorta measurement is crucial to report detailed aneurysm extension which might affect the strategy of interventional repair. AI assistance promises improved reporting efficiency and has high potential to reduce radiologist's inter-reader variabilities that can hamper diagnostic follow-up accuracy. KEY POINT: The time-consuming guideline-compliant aorta aneurysm assessment is crucial to report aneurysm extension in detail; AI-assisted measurement reduces reporting time, improves extension evaluation and reduces inter-reader variability.

Portal hypertension is the main driver of liver stiffness in advanced liver cirrhosis.

Liver stiffness (LS) is a novel non-invasive parameter widely used in clinical hepatology. LS correlates with liver fibrosis stage in non-cirrhotic patients. In cirrhotic patients it also shows good correlation with Hepatic Venous Pressure Gradient (HVPG). Our aim was to assess the contribution of liver fibrosis and portal hypertension to LS in patients with advanced liver cirrhosis. Eighty-one liver transplant candidates with liver cirrhosis of various aetiologies underwent direct HVPG and LS measurement by 2D shear-wave elastography (Aixplorer Multiwave, Supersonic Imagine, France). Liver collagen content was assessed in the explanted liver as collagen proportionate area (CPA) and hydroxyproline content (HP). The studied cohort included predominantly patients with Child-Pugh class B and C (63/81, 77.8%), minority of patients were Child-Pugh A (18/81, 22.2%). LS showed the best correlation with HVPG (r=0.719, p< 0.001), correlation of LS with CPA (r=0.441, p< 0.001) and HP/Amino Acids (r=0.414, p< 0.001) was weaker. Both variables expressing liver collagen content showed good correlation with each other (r=0.574, p<0.001). Multiple linear regression identified the strongest association between LS and HVPG (p < 0.0001) and weaker association of LS with CPA (p = 0.01883). Stepwise modelling showed minimal increase in r2 after addition of CPA to HVPG (0.5073 vs. 0.5513). The derived formula expressing LS value formation is: LS = 2.48 + (1.29 x HVPG) + (0.26 x CPA). We conclude that LS is determined predominantly by HVPG in patients with advanced liver cirrhosis whereas contribution of liver collagen content is relatively low.

Acute Liver Failure due to Amanita phalloides Poisoning: Therapeutic Approach and Outcome.

INTRODUCTION: Amanita phalloides poisoning is a potentially fatal cause of acute liver failure. The aim of this study was to analyze the impact of initial patients' characteristics and different treatment modalities on the outcome of patients with liver failure caused by Amanita poisoning. MATERIAL AND METHODS: We retrospectively evaluated 23 patients admitted to our center between July 2007 and August 2016. RESULTS: Mean time interval between Amanita phalloides ingestion and the onset of gastrointestinal symptoms was 12.48 ± 9.88 hours and the interval between ingestion and hospital admission 26.26 ± 15.14 hours. The treatment was intiated by oral decontamination using activated charcoal followed by intravenous rehydration and high doses of intravenous N-acetylcysteine and silibinin. Fourteen patients (61%) underwent extracorporeal elimination method. Ten patients had plasmapheresis, 1 patient had hemoperfusion, and 5 patients had fractionated plasma separation and adsorption. Seven patients who met King's College Criteria were listed for urgent liver transplantation; one of them died before transplantation. Six patients underwent liver transplantation; the mean waiting time was 6.5 ± 12.0 days (range, 1-31 days). One patient died 2 months afterward. All 16 patients who did not meet King's College Criteria and received conservative treatment survived. CONCLUSION: Our results documented a good prognostic value of standard King's College Criteria for indication of urgent liver transplantation in acute liver failure caused by Amanita phalloides poisoning. Fractionated plasma separation and adsorption may contribute to low mortality on the waiting list. Intensive care and extracorporeal elimination methods seem to be crucial points of the conservative treatment.

Acoustical properties of selected tissue phantom materials for ultrasound imaging.

This note summarizes the characterization of the acoustic properties of four materials intended for the development of tissue, and especially breast tissue, phantoms for the use in photoacoustic and ultrasound imaging. The materials are agar, silicone, polyvinyl alcohol gel (PVA) and polyacrylamide gel (PAA). The acoustical properties, i.e., the speed of sound, impedance and acoustic attenuation, are determined by transmission measurements of sound waves at room temperature under controlled conditions. Although the materials are tested for application such as photoacoustic phantoms, we focus here on the acoustic properties, while the optical properties will be discussed elsewhere. To obtain the acoustic attenuation in a frequency range from 4 MHz to 14 MHz, two ultrasound sources of 5 MHz and 10 MHz core frequencies are used. For preparation, each sample is cast into blocks of three different thicknesses. Agar, PVA and PAA show similar acoustic properties as water. Within silicone polymer, a significantly lower speed of sound and higher acoustical attenuation than in water and human tissue were found. All materials can be cast into arbitrary shapes and are suitable for tissue-mimicking phantoms. Due to its lower speed of sound, silicone is generally less suitable than the other presented materials.

[Cutaneous sarcoidosis during pegylated interferon alpha and ribavirin treatment of chronic hepatitis C--a case report]. / Sarkoidóza indukovaná interferonem: komplikace lécby hepatitidy C. Kazuistika.

Interferon-induced sarcoidosis is well documented. We report a case of sarcoidosis in a patient with hepatitis C virus infection treated with pegylated interferon alpha and ribavirin. The patient developed cutaneous sarcoidosis about 6 months after beginning of the combination therapy. Spontaneous regression of the lesions was noted after discontinuation of the treatment. Interferon-alpha is known to stimulate T helper cells with a TH-1 profile immune response, which is the key immunologic event of a sarcoid granuloma formation. In addition to its antiviral action, ribavirin also enhanced the TH-1 response. Incidence of drug induced sarcoidosis may be underreported, because many symptoms of sarcoidosis mimic the side-effects of interferon as fever, myalgias, arthralgias, fatigue and symptoms of pulmonary diseases.

[Diagnosis and treatment of chronic hepatitis B. Recommendations of the Czech Hepatology Society of the J. E. Purkinje Medical Society and the Society of Infectious Medicine of the J.E. Purkinje Medical Society]. / Diagnostika a lécba chronické hepatitidy B.

Chronic hepatitis B is one of the world's most common infectious diseases. In the Czech Republic it has a prevalence of 0.56%. Antiviral therapy for chronic hepatitis B demonstrably increases quality of life and where indication criteria are met and standard therapeutic procedures are followed, it is clearly cheaper than treatment for the complications of advanced cirrhosis of the liver or hepatocellular carcinoma. At the time of issuing of this recommendation, 4 medicines were classified for the treatment of chronic hepatitis B in the Czech Republic--pegylated interferon (IFN) alpha-2a, conventional IFN alpha, lamivudine (LAM) and adefovir dipivoxil (ADV). In a number of other developed states, entecavir (ETV) and telbivudine (LdT) have also been approved for treatment. The most effective treatment available at present is pegylated IFN alpha-2a, which should be the medication of first choice for initial treatment of hepatitis B, HBeAg positive and negative forms, provided that there are no contraindications for IFN alpha treatment. Conventional (standard, classical) IFN alpha can also be used, though clinical studies have shown it to be less effective than pegylated IFN alpha-2a. The main advantage of interferon compared to other commercially available medications is its relatively shorter and more clearly defined treatment period, the high probability of permanent suppression of virus replication and seroconversion of HBeAg/anti-HBe (in HBeAg positive forms of the illness) and the non-creation of mutant strains of HBV resistant to IFN in the course of treatment. If there are contraindications for IFN alpha (pegylated or conventional) or it is ineffective or poorly tolerated, ADV, ETV, LAM or LdT can be used. LAM and LdT treatments are often accompanied by the appearance of mutant strains of HBV, that are resistant to lamivudine or LdT and therefore they are not preferred.

Soluble T cell receptors: detection and quantitative assay in fluid phase via ELISA or immuno-PCR.

To establish the concentration range in which soluble murine T cell receptors (sTCR), derived from the Th2 clone D10, exhibited biological activity, and to follow production and purification of D10 sTCR, we devised four quantitative immunoassays: three ELISA systems, and an immuno-PCR assay. The direct ELISA, employed hamster anti-TCR beta monoclonal antibody (H57), which detects all types of alpha beta TCR, regardless of their variable regions, and had a detection limit of about 6 ng/ml sTCR. The indirect sandwich ELISA employed anti-V beta 8 as capture antibody, and had a detection limit of 600 pg/ml. With the direct sandwich ELISA, that also employed anti-V beta 8, TCR concentrations as low as 100 pg/ml could be detected. The ELISA assays were specific for soluble alpha beta TCR, and showed no cross-reactivity when employing two control hamster anti-gamma delta TCR mAbs (GL3 and UC7), or with anti-TCR beta and monoclonal hamster IgG as a control antigen. Further, we demonstrated that in some assays where use of passive binding ELISA plates resulted in a high background, replacement with covalent binding ELISA plates resulted in an acceptable low background value. With the immuno-PCR assay, concentrations of sTCR as little as 0.8 pg/ml could be detected. In summary, the assays described here may prove valuable in investigating the occurrence and amount of sTCR in vitro and in vivo.

The role of ERCP in management of biliary complications after liver transplantation.

Biliary complications remain to pose a serious problem in patients after liver transplantation. In the past, they occurred in as many as 50% of patients, and were associated with a height mortality. This has changed and at present the incidence of this complications is lower. The authors present their own series and discuss the role of ERCP in the management of complications.

[Interesting urinary findings in acute intermittent porphyria]. / Zajímavý mocový nález u akutní intermitentní porfyrie.

The authors describe an uncommon case of a patient with acute intermittent porphyria whose urine on standing, when exposed to light and air, turned dark and eventually black. The reason was increased excretion of porphobilin. The urine continued moreover increased amounts of Thormählen-positive substances, typical melanogens were not detected, however. The authors wish to draw attention to possible diagnostic errors which arise due to erroneous interpretation of laboratory results.

[A case of recurrent alimentary lead poisoning]. / Prípad opakované alimentární otravy olovem.

The authors describe a case of lead poisoning in a family (father, mother, son, daughter). The condition was at first diagnosed as acute hepatic porphyria. The correct diagnosis was made on the basis of increased urinary excretion of delta-aminolevulinic acid and coproporphyrin and on the basis of the revealed reversibly inhibited activity of delta-aminolevulinic acid dehydratase in red blood cells. The source of intoxication was the use of red lead pigment instead of dried red pepper.